Jane McCredie: Recruitment reward

THE rich nations of the world have in recent years become increasingly dependent on doctors and other health workers recruited from developing countries.

The practice hasn’t been without its critics, with the WHO’s code of practice saying states should discourage active recruitment from developing countries facing their own critical shortages of health workers.

A 2008 paper in The Lancet went further, arguing active recruitment of health workers from sub-Saharan Africa by wealthy countries such as Australia should be viewed as an international crime because of its contribution to “a measurable and foreseeable public-health crisis” in that region.

Intuitively, it does seem that recruiting doctors and nurses from some of the world’s poorest countries would have to contribute to poorer health outcomes in those areas, but a paper in the Journal of Medical Ethics last week questions that assumption.

Political theorist Dr Javier Hidalgo, from the University of Richmond in the US, defends the practice, arguing it does not generally have a harmful effect on health outcomes.

“Maybe organisations in rich countries, such as governments and non-profit organisations, should do more to promote the health-related interests of the global poor”, writes Dr Hidalgo, who specialises in ethics and public policy related to immigration.

“But there is good reason to doubt that organisations in rich countries can effectively promote the interests of people in poor countries by refraining from recruiting health workers from these countries”, he writes.

It sounds unlikely, and more than a little convenient for countries like ours that have active overseas recruitment programs, but Dr Hidalgo writes that he found little or no evidence of a causal relationship between emigration of health workers and poorer health outcomes.

How can this be?

One possible reason is that migrants send money back to their family providing income that helps to counterbalance any negative effects from their departure. Another is that the option of working overseas might encourage more people to train as health professionals, thus increasing the local workforce.

Some of the other explanations suggested by Dr Hidalgo seem more problematic on an ethical level. Many medical services in developing countries are provided by workers with more basic training rather than the doctors and nurses who are more likely to have the opportunity to migrate, he writes.

On top of that, poor infrastructure, low levels of literacy, and insufficient funds to employ health workers might all contribute to a situation where the skills of doctors and nurses are not being effectively used to improve health outcomes.

That last argument seems to boil down to something like: “The situation is so bad in some of these countries, we might as well take their health workers because it really can’t get any worse.”

I don’t for a moment question the ethics of people who choose to come and work in a country like Australia. They are entitled to seek the best future for themselves and their families, and an article in the New York Times earlier this year showed how agonising it can be for a doctor to move to the developed world.

But I’m not entirely convinced by Dr Hidalgo’s arguments either. Shouldn’t the wealthy countries that benefit from this migration take some responsibility for the state of health in the workers’ countries of origin?

Attempts to restrict recruitment of health workers from developing countries are probably impractical — and possibly unfair to the individuals involved — but maybe the developed nations of the world could agree on some real way of compensating the countries they leave behind for their loss.

If for every doctor Australia recruited from a country like Bangladesh or Sudan we were obliged to provide a certain amount of funding for medical education and health infrastructure, it might at least go some way towards positively improving health outcomes in those countries.

Jane McCredie is a Sydney-based science and medicine writer.

Posted 5 November 2012